Focal nodular hyperplasia is the second most common liver mass.
Appears as lobulated intrahepati lesions with central lucency (scar)
a large, round, low attenuated lesion with enhancing ring.
Rt lobe abscess + Rt hemidiaphragm elevation + recent travel =Amebic liver abscess
aspiration is not mandatory.
Typical echinococcal liver cyst in the right lobe of the liver.
sheepherder + cough + liver cyst with septations, eggshell calcification and hydated sand =Echincoccosis
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| Haptic adenoma |
Well demarcated mass with early enhancement in the arterial phase before iso-attenuation in the delayed phase. strongly associated with OCP. MRI spoked wheel appearance. Can rupture: resect/ embolise.
A 35-year-old woman with a 15 year history of oral contraceptive use presents with right upper quadrant abdominal pain and dyspepsia. The pain is exacerbated by deep breathing or coughing. An abdominal ultrasound is negative for gallstones or cholecystitis, but reveals the presence of a 6 cm subcapsular mass in the lateral left lobe of the liver which is heterogeneous in echotexture. Gadolinium contrast MRI shows a rapidly enhancing heterogeneous mass in the early arterial phase with return to baseline enhancement of the surrounding liver in the early portal venous phase. The lesion does not wash out and there is no central scar. There are no imaging features suggestive of liver cirrhosis and the spleen is normal in size. Laboratory tests show: a platelet count of 250 x 109/L (normal 150-450 x 109/L); INR 1.0 (normal 0.8-1.2); serum bilirubin 0.9 mg/dL (normal 0.3-1.3 mg/dL); AST 20 U/L (normal 0-35 U/L); ALT 24 U/L (normal 0-35 U/L); albumin 3.6 g/dL (normal 3.5-5.5 g/dL); and creatinine 0.8 mg/dL (normal 0.7-1.3 mg/dL). What would be the appropriate management of the liver mass at this time?
ReplyDeleteA. Surgical resection
B. Chemoembolization
C. Percutaneous alcohol injection
D. Observation
E. Cryoablation
Explanation
The description is of a mass with classical imaging characteristics of a hepatic adenoma. Adenomas are heterogeneous on imaging due to the presence of focal hemorrhage, necrosis, fibrosis, calcifications, and fat.
The occurrence of hepatic adenomas in a patient on oral contraceptives is typical; after 9 years of oral contraceptive use, the relative risk of hepatic adenomas is increased 25 to 40-fold.
The incidence of hepatic adenomas has been shown to decrease after reduction in the dose of estrogen in oral contraceptive pills.
Surgical resection has been recommended in the past for all hepatic adenomas when feasible. However, due to the increasing recognition of their generally benign course, resection is now usually only recommended for symptomatic adenomas or for those greater than 5 cm in size that are at higher risk of hemorrhage, rupture, or malignant transformation. Adenomas less than 5 cm in size are usually managed by discontinuation of oral contraceptive use and intermittent imaging follow-up.
Resection of adenomas less than 5 cm in size may also be recommended for women desirous of pregnancy, due to the risk of enlargement, hemorrhage, and rupture of adenomas during pregnancy.
The mass described here presents two indications for surgical resection, size greater than 5 cm, and symptoms of pleuritic type abdominal pain consistent with a symptomatic adenoma. Radiofrequency ablation is the most frequently used alternative therapy to surgical resection if the patient is not a candidate for surgery, surgery is technically not feasible, or resection of a very large proportion of the liver would be required. Chemoembolization, percutaneous ethanol injection, and cryoablation are generally not used for treatment of hepatic adenomas.
Asymptomatic, calcified cystic lesions in the liver are typical of hydatid cysts.
ReplyDeleteHydatid infection was endemic in sheep farming regions (such as Wales or New Zealand) in the past and sheep dogs were infected by eating infected offal. Humans contract hydatids via faecal/oral spread from dogs.
The liver cysts are usually asymptomatic and calcification usually denotes a non-viable cyst.
Ultrasonography is probably the most helpful initial test since it can usually differentiate a simple cyst from other cystic lesions. It should also be used for follow-up studies.
Hydatid serology has a sensitivity of 80-90%. If hydatid serology is negative then further imaging (CT/MRI) +/- aspiration may be required to make a diagnosis.
FNHs are the most common non-malignant hepatic tumor not of vascular origin.
ReplyDeleteThey are predominantly seen in females (8:1 ratio).
FNHs fall into the category of regenerative nodules as opposed to dysplastic or neoplastic nodules.
Since these are benign lesions, malignant transformation has rarely been reported. Once stability has been verified with repeat imaging, no further follow-up is needed.
A 75-year-old retired farmer from mid-Wales was found to have very mildly deranged liver function tests during a routine health check-up.
ReplyDeleteHe had an ultrasound scan which demonstrated multiple cystic lesions in the right lobe of the liver ranging in size from 1-8 cm in diameter. The larger cysts have a calcified appearance.
He had a melanoma removed from his back 20 years ago and has had multiple basal cell carcinomas removed from his head, face, and arms in recent years.
Which investigation should be carried out next?
1-CT scan
2-ERCP
3-Hydatid serology
4-Needle aspiration
4-Liver biopsy
Asymptomatic, calcified cystic lesions in the liver are typical of hydatid cysts.
Hydatid infection was endemic in sheep farming regions (such as Wales or New Zealand) in the past and sheep dogs were infected by eating infected offal. Humans contract hydatids via faecal/oral spread from dogs.
The liver cysts are usually asymptomatic and calcification usually denotes a non-viable cyst.
Ultrasonography is probably the most helpful initial test since it can usually differentiate a simple cyst from other cystic lesions. It should also be used for follow-up studies.
Hydatid serology has a sensitivity of 80-90%. If hydatid serology is negative then further imaging (CT/MRI) +/- aspiration may be required to make a diagnosis.
Melanoma metastases are not typically cystic and calcified.
Basal cell carcinomas are very common in those who work outside in the southern hemisphere, liver metastases are very uncommon.
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DeleteA patient who raises livestock for a living presents to your office after a CT scan obtained in the emergency department for abdominal pain reveals a calcified sharply circumscribed cyst containing two “daughter” cysts. Which of the following is the most likely diagnosis?
ReplyDelete1-Schistosomiasis
2-Entamoeba histolytica
3-Strongyloides
4-Echinococcus sp.
5-Metastatic colon cancer
This patient has risk factors for Echinococcus infection and a classic appearance of this infection on imaging. Infection occurs when humans eat vegetables contaminated by dog feces containing embryonated eggs. The eggs hatch in the small intestine and liberate oncospheres that penetrate the mucosa and migrate via vessels or lymphatics throughout the body. The liver is the most common destination (70%), followed by the lungs (20%), kidney, spleen, brain, and bone. In these organs, a hydatid cyst develops that produces numerous protoscolices, which reproduce asexually. Ultimately, the hydatid cyst ruptures and releases them to set up multiple additional daughter cysts. Characteristic cysts with ring-like calcifications along with septated cysts with multiple associated daughter cysts are seen on imaging.
A 28-year-old Hispanic man presents with a two-week history of abdominal pain, fever, malaise, and myalgias. He is found to have a fluid-filled abscess in his liver. The radiologist who aspirated the fluid for diagnostic purposes describes the aspirate as reddish brown and pasty. Trophozoites are identified on microscopic examination. Which of the following is the best treatment for this liver abscess?
ReplyDelete1-Third-generation cephalosporin
2-Resection
3-Metronidazole
4-Praziquantal
5-Albendazole
In the United States, amebiasis is a disease of young, often Hispanic, adults. Amebic liver abscess is the most common extraintestinal manifestation of amebiasis. Typical symptoms include abdominal pain, fever, malaise, myalgias, and arthralgias. During its life cycle, Entamoeba histolytica exists in trophozoite or cyst form. After infection, amebic cysts pass through the gastrointestinal tract and become trophozoites in the colon, where they invade the mucosa and produce typical flask-shaped ulcers. The organism is carried by the portal circulation to the liver, where an abscess may develop. Aspiration of this abscess may yield a reddish brown, pasty (“anchovy paste”) aspirate in which trophozoites are rarely identified. Treatment is with metronidazole. After treatment with metronidazole for seven to 10 days, eradication of residual amebae in the gut with agents such as iodoquinol, 650 mg three times daily for 20 days; diloxanide furoate, 500 mg three times daily for 10 days; and paromomycin, 25 to 35 mg/kg/day in three divided doses for seven to 10 days, is often recommended.
Focal nodular hyperplasia (FNH) occurs most commonly in women. Generally, FNH is a solitary, nonencapsulated, well circumscribed and lobulated mass that contains a central scar. On US, FNH usually appears as a homogenous iso- or slightly hypoechoic mass. the central scar is often diffcult to visualize with US, however when seen is usually hyperechoic and hypervascular with Doppler US. On CT, FNH is iso- to slightly hypoattenuating mass with contrast. During the arterial phase of enhancement, FNH shows immediate and intense enhancement (with exception of the central scar) becoming isodense to the liver during the portal venous phase. The central scar enhances on the delayed phase. Typical MR features of FNH are iso- or hypointensity on T1 weighted images and slight homogenous hyper- or isointensity on T2. The central scar is hyperintense on T2-WI because of the presence of water-rich loose myxomatous fibrous tissue. The MR enhancement pattern is identical to CT
ReplyDelete